Financial Assistance Grant Application

The information requested below is needed to complete the patient’s application for financial assistance with copays, deductibles and other related expenses associated with treatment of a current Multiple Sclerosis diagnosis. The patient will be notified of the application determination. If you have any questions about this application or the application process, please contact MS is BS New England Inc. at grants@MSisBSNewEngland.com.

Applicant Information

Section 1. (Required to be completed by healthcare provider)

Physician / Healthcare Provider responsible for ongoing patient care.

Section 2.

Diagnosis & Therapy

Section 3.

Funds Requested

Based on treatment, frequency, cost and co-pay, please let us know the total cost.

Section 4.

Application Declaration

I verify the information provided in my application is complete, accurate, and true. I further understand that our board as deemed necessary may verify the information provided. I understand that if I am approved for assistance by MS is BS New England Inc, assistance will be terminated if the board becomes aware of any fraudulent activity related to my application or the assistance provided to me by the foundation. I understand that any assistance the foundation may provide is limited to the terms and conditions established by the foundation and that the foundation reserves the right at any time and for any reason, without notice, to discontinue assistance.

I authorize the foundation and its board or other representatives to obtain health information from my healthcare providers and other information necessary to complete the application process or verify the accuracy of any information provided with this application.

Section 5.

Authorization to release Medical Information

In order for me to receive assistance through MS is BS New England Inc, I authorize my health care provider(s) and my insurance company(ies) to disclose to the foundation and its board and other representatives (collectively the foundation), information about me, my current medical condition and my health insurance coverage. The information can include spoken or written facts about me as well as copies of records from my health care provider(s) and my insurance company(ies) about my health or health care.

I understand that my health care provider(s) and insurance company(ies) will not condition my medical treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits on my signing of this authorization. I understand, however if I do not sign this authorization, I will not be eligible to receive assistance through the foundation. I may revoke this authorization at any time by mailing or emailing a signed letter of revocation to the foundation at the address listed below, but if I revoke this authorization, I will no longer be able to receive assistance through the foundation. Additionally I can tell my healthcare provider(s) and my insurance company(ies) in writing that I do not want them to share any more information with the foundation, but it will not change any actions the foundation, my health care provider(s) or my insurance company(ies) took before I revoke this authorization.

I understand that the foundation will use and give out this information to see if I qualify for assistance and to run the foundation. In addition, the foundation may use and give out my information to refer me to, or to determine my eligibility for other programs, foundations or alternate sources of funding or coverage that may be available to provide assistance to me with the cost of my drugs and treatments. I understand that the foundation will make every effort to keep my information private.

This authorization expires the later of one year after the date it is signed or until I am no longer participating in the foundation program. I am entitled to a copy of this authorization.

If signing on behalf of the patient:

I verify that the applicant has authorized me to sign, on her or her behalf, the "Declaration" and "Authorization to Release Medical Information" which I have read to the applicant in full. By signing this, I am attesting to the fact that I have received such intentional and informed authorization from the applicant to sign the "Declaration" and "Authorization to Release Medical Information" on his or her behalf.

Waiver and Release of Liability

In consideration for being potentially considered to participate in programs, events, and or activities sponsored by MS is BS New England Inc, I, for myself, my executor, administrators, heirs, and anyone entitled to act on my behalf, hereby waive discharges and covenant not to sue MS is BS New England Inc, its management, officers, board members, members, sponsors, licensees, volunteers, their successors, and all for any and all liability, claims, demands, damages, causes of action, losses, or expenses arising out of my participation in the event and any related activities.

I understand that I may be photographed, filmed, or videotaped in connection with my involvement with MS is BS New England Inc. I hereby irrevocably grant to MS is BS New England Inc, its affiliates, licensees, and collaborators the absolute right and permission to distribute, publish, exhibit, digitize, broadcast, display, reproduce, photograph, videotape or otherwise use my name, picture, portrait, likeness, writings or biographical information (including if applicable, information regarding my disease diagnosis, prognosis and treatment), manner or media whatsoever anywhere in the world in perpetuity for any lawful purpose whatsoever, including without limitation, for editorial, educational, promotional, and advertising purposes, for the solicitation of contributions, as evidence in litigation, and for any other purposes in furtherance of the purposes and

objectives of MS is BS New England Inc. I hereby release discharge and agree to save harmless MS is BS New England Inc. and its employees or agents, affiliates, legal representatives or assigns, and all persons acting under its permission or upon its authority, from any liability by virtue of any publication of my likeness, including, without limitation, claims for libel or invasion of privacy. I further agree that MS is BS New England Inc. shall be the exclusive owner of all copyright and other rights in such media.

I have carefully read this Waiver and Release of Liability and fully understand its contents. I am at least 18 years of age and I am competent to contract in my own name. I am aware that this is a release of liability and a binding contract between myself and the persons and entities mentioned above and I sign it of my own free will. I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this Waiver and Release freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.